Deck 8: Patient Record Requirements

Question 1

That part of the health record used for continuity of care is the _____ information.

A) Clinical
B) Demographic
C) Financial
D) Legal

Answer 1

Clinical

Question 2

Federal and state statutes (laws) that directly impact the quality of the health record include requirements about _____.

A) Documentation requirements
B) Filing claims on time
C) Justifying staffing needs
D) Transitioning to an EHR

Answer 2

Documentation requirements

Question 3

Regulations concerning medical records may control _____.

A) How they are to be maintained
B) The organization of the UB-04
C) Procedures performed by a provider
D) Ways they are photocopied

Answer 3

How they are to be maintained

Question 4

What is a process in development to combat increased costs associated with the legal discovery of the electronic health record?

A) ECRM
B) HIPAA
C) MMA
D) UNOS

Question 5

Record retention policies address _____,

A) The length of time a record is maintained
B) When the record can be released to the patient
C) Whether a patient's record warrants storage
D) Which records can be provided pursuant to court order

Question 6

The use of physician handwritten signature stamps to authenticate health record entries _____.

A) Has been eliminated by CMS
B) Is considered acceptable by CMS
C) Proves to be a best practice standard
D) Saves time for physicians and their designees

Question 7

In a negligence claim, the standard of care that considers the prevailing is the _____.

A) Federal statute/regulation
B) Hospital standard or policy
C) State statute/regulation
D) Standard that is higher

Question 8

ECRM legislation controls _____.

A) All forms of data and the tools used to generate and store it
B) Just the contents of electronic tools, such as computers
C) Only business and financial records maintained on patients
D) Privacy and confidentiality of healthcare information

Question 9

Which of the following are subject to strict legal requirements?

A) Abstract record
B) Electronic record
C) Paper-based record
D) Records, regardless of format

Question 10

When an error is made in the healthcare record, _____.

A) An addendum to the EHR or paper-based record should be documented, leaving the original entry in place
B) Eliminating the erroneous information by using correction fluid in a paper-based record is an acceptable practice
C) Make sure that the erroneous entry is deleted in its entirety, and the correct information is entered
D) The correction to the record should be made by the healthcare provider's supervisor to
Enhance reliability

Question 11

Regulations about medical records are enforced by _____.

A) Accreditation organizations
B) Federal and state agencies
C) Medical societies
D) Professional associations

Question 12

Authorship of a health record entry may be complicated by _____.

A) Allowing the user to copy and paste, possibly into the wrong record
B) Authenticating the identification of the person making the entry
C) Taking care not to repeat entries that are no longer acceptable
D) The patient's right to alter or delete unsatisfactory entries

Question 13

If an item was not charted in a health record, it is presumed that _____.

A) If it wasn't documented, it wasn't done
B) It was not necessary to document that item
C) Providers can be excused for being too busy delivering care to document
D) When an order is written, it was carried out even if not documented as such

Question 14

The destruction of records _____.

A) Can be done when requests for the production of documents legally endangers an organization
B) Is performed at the discretion of the health information manager due to storage concerns
C) May be performed in the regular course of business following a specified retention period
D) Should never be performed so that the integrity of patient care is consistently maintained

Question 15

Which is a major concern regarding the destruction of records?

A) Information that identifies patients must be maintained as confidential.
B) Prohibitive costs impact the quality of care provided to patients.
C) Regulatory agencies might not have been informed about the destruction.
D) Third parties must never be used for destruction of sensitive information.

Question 16

The legal health record is defined as that containing the _____.

A) Complete and accurate description of the patient's history, condition, and care provided
B) Electronic and legal signatures of health care providers and ancillary staff members
C) Format or method by which information documented in the health record is stored
D) Type of testing performed, including data from the chargemaster or encounter form

Question 17

If a patient requests that his health record be corrected or altered, the provider may accomplish this by _____.

A) Deleting the original information and documenting the corrected information
B) Denying the patient's request by informing the patient of this in writing
C) Refusing to make corrections/alterations because patients don't have this right
D) Requiring that a local judge review the patient's request to correct or alter data

Question 18

Which is an example of acceptable authentication of a medical record entry?

A) Nurse who authenticates notes documented by another nurse who went off shift.
B) Nurse practitioner who authenticates notes documented by the physician.
C) Physician who authenticates reports dictated by colleagues within his practice.
D) Specialist who authenticates his own dictated report electronically using a password.

Question 19

Institutional standards of care _____.

A) Are enforceable by federal and state law
B) Can be lower than state and federal regulations
C) Do not carry the force of law
D) Have no bearing on establishing negligence

Question 20

The phrase deeming authority means to substitute compliance with _____.

A) Accreditation standards for compliance with CMS regulations
B) CMS regulations for compliance with state standards
C) Federal or state statutes (laws) with accreditation standards
D) Quality review organization requirements with federal regulations

Question 21

When an incorrect entry is documented in the electronic health record (EHR), the responsible provider documents the correction as an addendum in a new document and a(n) _____ links the original document (that contains the incorrect entry) to the addendum.

A) Computer code
B) E-signature
C) Nursing entry
D) Physician order

Question 22

The health record is defined as the _____ record generated at or by the health care provider or organization, which documents treatments and services delivered during the patient's episode of care by the provider or organization.

A) Business
B) Legal
C) Medical
D) Valid

Question 23

After the destruction of records, a certificate of destruction ____.

A) Applies only if the destruction of records was performed by a third party
B) Indicates what was destroyed as well as the method of destruction
C) May implicate the healthcare organization and providers in a legal action
D) Often proves unnecessary because the health records no longer exist

Question 24

Storage constraints, new technology, and fiscal concerns are all forces influencing retention of health information.

Question 25

The release of health records from drug and alcohol abuse programs is governed by _____ regulations.

A) County
B) Federal
C) Municipal
D) State

Question 26

Describe what a certificate of destruction is and how long it should be kept?

Question 27

J.C. and AOA are accrediting bodies.

Question 28

Which is an example of personal information associated with the health record?

A) Alcohol, tobacco, and work history
B) Demographic data, such as address
C) Test results and operative reports
D) Third-party payer information

Question 29

A nurse writes a verbal order from a physician on the physician order sheet in the health record; the nurse is the _____ of the entry.

A) Authenticator
B) Author
C) Editor
D) Transcriber

Question 30

When a health care facility files for bankruptcy and closes, a _____ is appointed to make decisions for the bankrupt health care provider.

A) Case trustee
B) Federal agency
C) Licensing authority
D) Third-party payer

Question 31

Describe the best way to make a correction to a paper based record.

Question 32

Which is an example of financial information associated with the health record?

A) Alcohol, tobacco, and work history
B) Demographic data, such as address
C) Test results and operative reports
D) Third-party payer information

Question 33

Which is an example of social information associated with the health record?

A) Alcohol, tobacco, and work history
B) Demographic data, such as address
C) Test results and operative reports
D) Third-party payer information

Question 34

Which is an example of medical information associated with the health record?

A) Alcohol, tobacco, and work history
B) Demographic data, such as address
C) Test results and operative reports
D) Third-party payer information

Question 35

A health record is used for clinical and nonclinical reasons.

Question 36

Enterprise content and record management (ECRM) aids in combating potential increased costs associated with the discovery process. An example of an enterprise management principle is _____.

A) creating both digital and analog records for use in the facility
B) differentiating between clinical and nonclinical health record content
C) policies establishing about how long to save emails and text files
D) streamlining the process of responding to discovery requests

Question 37

A hybrid record is part paper and part electronic.

Question 38

Which is an example of a nonclinical use of the health record?

A) Billing to and reimbursement by third-party payers.
B) Chronological documentation of patient care.
C) Public health monitoring to determine flu outbreaks.
D) Quality improvement activities, such as infection control.

Question 39

Billing and reimbursement is a clinical use for a health record.